In America’s big cities, a walk down the street or a wait for the subway can be an exercise in avoidance. Scores of commuters in Los Angeles, New York and elsewhere don metaphorical blinders every day in order to ignore those sleeping fitfully on the train or battling psychosis on the street. Such indifference is morally fraught, but it is also a reflection of how common homelessness and public displays of mental illness have become.

在美國的大城市里，沿街散步或等地鐵都是一種躲避行為。在洛杉磯、紐約和其他地方，許多通勤者每天都戴著“隱形”眼罩，以忽略那些在火車上斷斷續(xù)續(xù)地睡覺或在街上與精神病抗爭的人。這種冷漠在道德上令人擔憂，但這也反映出無家可歸和公開展示精神疾病的現(xiàn)象已經(jīng)變得多么普遍。

Most Americans who experience homelessness do so briefly. They stay with family or crash on a friend’s couch until they can afford rent. (The lack of affordable housing is the biggest driver of homelessness.) The Department of Housing and Urban Development’s latest count of homeless people, tallied on a single night in January, found that 22% of them are “chronically homeless”, and that there were 16% more perennially homeless adults in 2022 than in 2020. Many live in tents beneath highways or in public parks. They are more likely to be suffering from drug addiction and mental illness, both of which can be made worse by living on the streets. The number of people sleeping outside has increased by roughly 3% since 2020, cancelling out the modest decline of people in shelters. As the ranks of unsheltered people have grown, an old question re-emerges: how should government help people who may not be able to help themselves?

大多數(shù)經(jīng)歷過無家可歸的美國人都短暫的這么做過。在付得起房租之前，他們要么住在家人家里，要么睡在朋友家的沙發(fā)上。(經(jīng)濟適用房的缺乏是導致無家可歸的最大原因。) 美國住房和城市發(fā)展部HUD在1月份的一個晚上對無家可歸者的人數(shù)進行了最新統(tǒng)計，統(tǒng)計發(fā)現(xiàn)其中22%的人是“長期無家可歸者”，2022年長期無家可歸的成年人比2020年多16%。許多人住在高速公路下或公園里的帳篷里。他們更有可能患有毒癮和精神疾病，流浪街頭會使讓兩種疾病變得更加嚴重。自2020年以來，露宿街頭的人數(shù)增加了約3%，這與避難所人數(shù)的小幅下降相抵消。隨著得不到庇護的人越來越多，一個老問題再次出現(xiàn): 政府應(yīng)該如何幫助那些可能無法自助的人?

The places most troubled by this, New York City and California, are trying to find an answer. Both have enacted policies aimed at people who are homeless and suffering from a psychotic disorder, such as schizophrenia. Yet they differ in important ways. Last month Eric Adams, the Democratic mayor of New York City, instructed police and first responders to hospitalise people with severe mental illness who are incapable of looking after themselves. Mr Adams’s plan is a reinterpretation of existing rules. Law-enforcement and outreach workers can already remove people from public places if they present a danger to themselves or others. But now, the mayor stressed, people can be hospitalised if they seem merely unable to care for themselves. “It is not acceptable for us to see someone who clearly needs help and walk past them,” Mr Adams proclaimed.

紐約和加利福尼亞州是受此困擾最嚴重的地方，它們正試圖找到答案。這兩個地區(qū)都制定了針對無家可歸者和精神分裂癥等精神障礙患者的政策。然而，這些政策在一些重要方面存在差異。上個月，紐約市長、民主黨人埃里克?亞當斯指示警察和急救人員，將無法自理的嚴重精神疾病患者送進醫(yī)院。亞當斯先生的計劃是對現(xiàn)有規(guī)則的重新解釋。如果有人對自己或他人構(gòu)成危險，執(zhí)法人員和外聯(lián)工作人員已經(jīng)可以將他們從公共場所趕走。但現(xiàn)在，市長強調(diào)，如果人們似乎僅僅是無法照顧自己，他們就可以住院治療。亞當斯先生宣稱:“ 我們不能接受看到明顯需要幫助的人卻從他們身邊走過。”

The mayor’s plan follows a policy change on the opposite coast. At the urging of Gavin Newsom, California’s Democratic governor, the state legislature passed the Community Assistance, Recovery, and Empowerment (CARE) Act in September , creating a new civil-court system aimed at directing the mentally ill and homeless to treatment and housing. Patients can be referred to CARE court by police, outreach workers, doctors or family members, among others.

市長的計劃是根據(jù)對岸的政策變化而制定的。在加州州長、民主黨人加文·紐森的敦促下，加州立法機構(gòu)于9月通過了《社區(qū)援助、康復和賦權(quán)法案》(CARE)，建立了一個新的民事法庭系統(tǒng)，旨在指導精神疾病患者和無家可歸者接受治療并提供住房。病人可以由警察、外聯(lián)工作人員、醫(yī)生或家庭成員等人轉(zhuǎn)診到CARE法庭。

Acceptance into the system means court-ordered treatment for up to two years, after which patients can “graduate” or, potentially, be subjected to more restrictive care, such as a conservatorship. California has been quick to try to distance CARE court from New York’s apparently more punitive response. “It’s a little bit like apples and giraffes,” says Jason Elliott, Mr Newsom’s deputy chief of staff. “We’re both trying to solve the same problem, but with very different tools at our disposal, and also really different realities.”

被該系統(tǒng)接受意味著法院下令進行長達兩年的治療，之后患者可以“畢業(yè)”，或者可能受到更嚴格的護理，比如監(jiān)護。加州迅速行動以試圖將CARE法庭與紐約那顯然更具懲罰性的回應(yīng)拉開距離?！斑@有點像蘋果和長頸鹿之間的關(guān)系（意指“毫不相干/不同”），”紐森的副幕僚長杰森?埃利奧特表示?！拔覀兌荚谠噲D解決同樣的問題，但我們使用的工具非常不同，現(xiàn)實情況也非常不同?！?/p>

The biggest difference between the two policies is their size. Because New York City recognises a right to shelter, the vast majority of the roughly 68,000 homeless people there have a roof over their heads. Experts reckon that Mr Adams’s order may at first affect only those few hundred people in the most dire straits. The California Policy Lab at the University of California estimates that 10% of unsheltered people in Los Angeles who took part in street outreach programmes had been diagnosed with a psychotic disorder of the kind that CAREcourt is supposed to help manage. Because more than 100,000 Californians are sleeping rough, the state thinks that up to 12,000 people may initially be eligible for treatment.

這兩項政策最大的不同在于它們的規(guī)模。由于紐約市認可庇護權(quán)，該市約6.8萬名無家可歸者中的絕大多數(shù)人都有棲身之所。專家們認為亞當斯先生的命令一開始可能只會影響到那些處境最艱難的幾百人。加州大學的加州政策實驗室估計，在洛杉磯參加街頭外展項目的無家可歸者中，有10%被診斷患有carec法庭應(yīng)幫助管理的那種精神疾病。由于超過10萬加州人露宿街頭，該州認為最初可能有多達1.2萬人有資格接受治療。

A swinging pendulum

The schemes may be different, but the outrage they inspire is similar. Any discussion of compulsory treatment for the mentally ill is tangled up in a decades-long fight over the balance between protecting people’s civil liberties and bodily autonomy, and ensuring their safety and that of others. Officials and critics alike are squeamish about any reform that evokes the horrors of state-run asylums in the 20th century, which were often unsanitary, overcrowded and understaffed, and sometimes just cruel. When government-run hospitals were shut down, community-based care was supposed to take their place. Instead, patients were often discharged to underfunded boarding houses and shelters. “We have not only abandoned people with severe mental illness to the jails, but also to the streets,” says Elizabeth Bromley, a psychiatrist at UCLA.

這些方案可能有所不同，但它們引發(fā)的憤怒卻是相似的。任何關(guān)于對精神疾病的強制的討論，都與長達數(shù)十年的斗爭糾纏在一起，其中斗爭的焦點主要是在保護人們的公民自由和身體自主權(quán)，以及確保他們和其他人的安全之間取得平衡。官員和評論家們都對任何會讓人想起20世紀官方收容所的不愉快經(jīng)歷的改革都感到不安，這些收容所通常不衛(wèi)生，人滿為患，人手不足，有時甚至很殘忍。當政府經(jīng)營的醫(yī)院被關(guān)閉時，社區(qū)醫(yī)療應(yīng)該取而代之。相反，病人經(jīng)常被送到資金不足的寄宿公寓和收容所。加州大學洛杉磯分校的精神病學家伊麗莎白·布羅姆利說:“我們不僅把患有嚴重精神疾病的人扔進監(jiān)獄，還把他們?nèi)拥浇稚??！?/p>

Many liberals blame Ronald Reagan for the government’s abandonment of mentally ill Americans. As governor of California in 1967, Reagan signed a landmark bill for patients’ rights, but then cut funding for mental-health care. As president in 1981, he rescinded federal funds for state mental-health services. But Alex Barnard, a sociologist at New York University, argues that heaping blame on Reagan is too simple. “Many administrations in California have had opportunities to reverse Reagan,” he says. Perpetuating the myth of Reagan’s total culpability, he adds, is “a way of distracting ourselves from the real challenge of building a system today that meets people’s needs, rather than just wishing we had it 50 years ago.”

許多自由主義者指責羅納德·里根拋棄了患有精神疾病的美國人。1967年，作為加州州長，里根簽署了一項具有里程碑意義的病人權(quán)利法案，但隨后削減了精神健康保健的資金。1981年擔任總統(tǒng)時，他取消了為州精神健康服務(wù)提供的聯(lián)邦資金。但紐約大學社會學家亞歷克斯·巴納德認為，把責任推到里根身上是件簡單的事。他表示，“加州的許多政府都有機會推翻里根”。他補充說，持久化里根完全有罪的錯誤觀念是“在分散我們注意力，讓我們忽視今天建立一個滿足人們需求的體系的真正挑戰(zhàn)，而不是只是希望我們50年前就擁有它?！?/p>

Civil-rights advocates in both states worry that the new policies herald a swing of the pendulum back towards confinement. It is unclear how often mentally ill people are detained for examination or treatment, but recent research suggests that the average yearly detention rate in 22 states increased by 13% between 2012 and 2016. Many critics argue that involuntary treatment is not only brutal, but ineffective. But the evidence is mixed and conducting research is tricky, says Mr Barnard. “You can’t randomly assign people to voluntary and involuntary treatment if you think that somebody is at risk of killing themselves,” he explains. Mr Adams’s plan and Mr Newsom’s CARE court both aim to exhaust options for voluntary treatment before mandating medication or hospital.

這兩個州的民權(quán)倡導者擔心，新政策預(yù)示著鐘擺將再次轉(zhuǎn)向監(jiān)禁。目前尚不清楚精神病患者被拘留檢查或治療的頻率，但最近的研究表明，2012年至2016年，22個州的平均年拘留率增加了13%。許多批評人士認為，非自愿治療不僅殘忍，而且無效。但巴納德表示，證據(jù)是復雜的，進行研究也很棘手。他解釋說:“如果你認為某人有自殺的風險，你就不能隨機地將他們分配到自愿和非自愿的治療中。”亞當斯先生的計劃和紐森先生的CARE法庭都旨在在強制藥物治療或醫(yī)院治療之前，用盡自愿治療的選擇。

Logistical questions abound, too. Luke Bergmann, the director of behavioural health services in San Diego County, worries about how severely ill, often isolated patients are supposed to travel to their court appointments, and whether there will be enough beds in long-term care facilities to house them. Watchdogs on both coasts wonder what kind of clinical training police will receive, and whether racial bias will lead to worse outcomes for black and Hispanic homeless people. Brian Stettin, Mr Adams’s senior adviser for mental health, admits that confrontations with police can be traumatic, and stresses that cops will work alongside medical workers.

后勤方面的問題也很多。圣地亞哥縣行為健康服務(wù)中心主任盧克·伯格曼擔心，病情嚴重、經(jīng)常被隔離的患者應(yīng)該如何前往法院，以及長期護理機構(gòu)是否有足夠的床位容納他們。兩岸的監(jiān)管機構(gòu)都想知道警察將接受什么樣的臨床培訓，以及種族偏見是否會導致黑人和西班牙裔無家可歸者的結(jié)果更糟。亞當斯先生的心理健康高級顧問布萊恩·斯泰廷承認，與警察的對抗可能會造成創(chuàng)傷，并強調(diào)警察將與醫(yī)務(wù)人員一起工作。

That Mr Newsom and Mr Adams are rethinking involuntary treatment reflects the failures of America’s mental-health system, but also their recognition that homelessness represents a political problem for their administrations—and their careers. As unsheltered homelessness has grown, Americans have become accustomed to public displays of profound suffering. Californians routinely say that homelessness is one of the most important issues facing the state; New Yorkers worry most about crime.

紐森和亞當斯重新思考非自愿治療反映了美國精神健康系統(tǒng)的失敗，但也反映了他們認識到無家可歸對他們的政府和他們的職業(yè)生涯來說是一個政治問題。隨著無家可歸者的增多，美國人已經(jīng)習慣了在公眾面前展示他們深切的痛苦。加州人經(jīng)常說，無家可歸是該州面臨的最重要的問題之一; 紐約人最擔心的是犯罪問題。

Allowing the mentally ill to languish in the streets contributes to a feeling that public safety and quality of life in America’s biggest cities are deteriorating. Mr Newsom and Mr Adams are two of the Democratic Party’s most charismatic and ambitious politicians. Should either seek higher office one day, they will be asked what they did to solve the hardest problems in their respective domains. Now they will at least have an answer.

讓精神疾病患者在大街上受苦，會讓人覺得美國大城市的公共安全和生活質(zhì)量正在惡化。紐森和亞當斯是民主黨最有魅力、最有雄心的兩位政治家。如果有一天他們尋求更高的職位，他們將被問及他們是如何解決各自領(lǐng)域中最棘手的問題的。現(xiàn)在他們至少有了一個答案。